Using one system of care from Canada and one from the United States, this Clinical Case Conference explores the similarities and differences between systems of care providing mental health services for children, adolescents, and families in the two countries. Ethical and clinical dilemmas arising in service systems for children and adolescents and their families are explored. These dilemmas are due to the absence of implementation or the incomplete implementation of key principles and practices that are outlined. Differences and similarities between ethical and clinical dilemmas in the United States and Canada are identified, and appropriate approaches to resolving these dilemmas are discussed.